Improving clinical outcome in patients with intestinal failure using individualised nutritional advice

Background:  Patients with intestinal failure are required to adhere to a complex regimen. Written information may increase knowledge leading to improvements in clinical outcomes. The present study aimed to evaluate the effectiveness of nutrition advice incorporating the use of a booklet.
Methods:  Each patient completed a questionnaire evaluating their knowledge of the regime and quality of life and kept a diet and gastrointestinal output diary. The diary was assessed and they were given the booklet with a verbal explanation tailored to individual requirements. The booklet explained the causes of intestinal failure, diet and fluid recommendations in relation to intestinal anatomy, information on medications and long-term monitoring. Patients were reassessed at their next appointment using the same tools. The primary endpoint was an improvement in knowledge. Secondary endpoints were an improvement in oral nutritional intake, nutritional status, quality of life and the content of home parenteral nutrition.
Results:  Forty-eight patients completed the study. Knowledge improved significantly after dietetic intervention in association with the provision of the booklet ( P  < 0.001). Oral energy ( P  = 0.04) and fat ( P  = 0.003) intake increased with an improvement in body mass index ( P  = 0.02). Patients on home parenteral nutrition showed a reduction in parenteral energy ( P  = 0.02), nitrogen ( P  = 0.003), volume ( P  = 0.02) and frequency ( P  = 0.003).
Conclusions:  A booklet for patients with intestinal failure in conjunction with personalised dietary counselling improves knowledge and clinical outcomes.     

The effect of simulator training on clinical skills acquisition, retention and transfer

Context  Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited.
Objectives  Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer.
Methods  We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation.
Results  Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P  < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P  = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P  = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P  = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P  = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P  = 0.8).
Conclusions  Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.     

Development and implementation of a science training course for breast cancer activists: Project LEAD (leadership, education and advocacy development)

Objective  To develop and implement Project LEAD (leadership, education, and advocacy development), a science course for breast cancer activists.
Population  Students were breast cancer activists and other consumers, mainly affiliated with advocacy organizations in the United States of America.
Setting  Project LEAD is offered by the National Breast Cancer Coalition; the course takes place over 5 days and is offered 4 times a year, in various cities in the United States of America.
Results  The Project LEAD curriculum has developed over 5 years to include lectures, problem-based study groups, case studies, interactive critical appraisal sessions, a seminar by an 'expert' scientist, role play, and homework components. A core faculty has been valuable for evaluating and revising the course and has proved necessary to provide consistent high quality teaching. Course evaluations indicated that students gained critical appraisal skills, enhanced their knowledge and developed confidence in selected areas of basic science and epidemiology.
Conclusions  Project LEAD comprises a unique curriculum for training breast cancer activists in science and critical appraisal. Course evaluations indicate that students gain confidence and skills from the course.     

混合教育模式对大学新生睡眠干预效果分析

目的 探讨睡眠教育项目对大学新生睡眠时间、知识、态度、习惯及日间嗜睡的影响,为改善大学生的睡眠状况提供参考。方法 采用整群抽样法,选取北京市某高校大一新生为研究对象(实验组前测288人,后测187人,追访108人;对照组前测207人,后测105人),将睡眠教育内容嵌入其他课程,采用混合教育模式对实验组进行为期10周的干预,对照组不做干预。两组人员分别在基线和干预后2周进行问卷评估,实验组在后测后9个月进行追访。结果 干预后,与对照组相比,实验组学习日和周末就寝时间分别提前21,17 min(t值分别为-2.78,-2.15,P值均<0.05);实验组学习日夜睡眠时长长于对照组19 min(t=3.51,P<0.01)。实验组睡前带电子产品上床现象和入睡不拖延、睡眠知识、睡眠态度、睡眠习惯、日间嗜睡得分均优于对照组(χ²/t值分别为9.15,2.82,5.71,3.98,2.41,-4.90,P值均<0.05)。与干预前相比,干预后实验组学习日和周末就寝时间分别提前11,17 min(t值分别为3.50,3.67,P值均<0.01),学习日和...     

Construct Validity of the Work Productivity and Activity Impairment Questionnaire across Informal Caregivers of Chronically Ill Older Patients

Objectives:  To assess the validity of the Work Productivity and Activity Impairment questionnaire as adapted for caregiving (WPAI:CG) to measure productivity loss (hours missed from work, impairment while at work, and impairment in regular activities) due to unpaid caregiving for medically complex older adults.
Methods:  The WPAI:CG was administered along with the Caregiver Strain Index (CSI) and Center for Epidemiologic Studies Depression Scale (CESD) to a caregiving population (N = 308) enrolled with their older, medically complex care-recipient in a cluster-randomized controlled study. Correlation coefficients were calculated between each productivity variable derived from the WPAI:CG and CSI/CESD scores. Nonparametric tests for trend across ordered groups were carried out to examine the relationship between each productivity variable and the intensity of the caregiving.
Results:  Significant positive correlations were found between work productivity loss and caregiving-related strain ( r  = 0.45) and depression ( r  = 0.30). Measures of productivity loss were also highly associated with caregiving intensity ( P  < 0.05) and care-recipient medical care use ( P  < 0.05). The average employed caregiver reported 1.5 hours absence from work in the previous week and 18.5% reduced productivity while at work due to caregiving. Employed and nonemployed caregivers reported 27.2% reduced productivity in regular activities in the previous week.
Conclusion:  The results indicate high convergent validity of the WPAI:CG questionnaire. This measure could facilitate research on the cost-effectiveness of caregiver-workplace interventions and provide employers and policy experts with a more accurate and comprehensive estimate of caregiving-related costs incurred by employers and society.     

Time spent on clerkship activities by students in relation to their perceptions of learning environment quality

Context  Students' perceptions of their learning environment are of great importance to their learning process. In this study we assessed the time allocated by students to clerkship activities and the relationship between students' allocations of time and their perceptions of the quality of their clinical learning environment.
Methods  Participants were 133 undergraduate students from eight hospitals taking part in four clerkship rotations. All students recorded the time they spent on eight clerkship activities over 2 weeks and completed the Postgraduate Hospital Educational Environment Measure (PHEEM). Partial correlation analyses were undertaken to examine the relationship between the amount of time students spent on each activity and their PHEEM scores.
Results  Students spent nearly 8 hours a day on clerkship activities. Most time was spent on observing doctors (40%), followed by participating in consultations without direct supervision (12%). The time students spent on observing doctors ( r  = 0.206, P  < 0.05) and in consultations without direct supervision ( r  = 0.211, P  < 0.05) was significantly related to the students' PHEEM scores. There was a significant relationship at the P  < 0.10 level between the time spent on directly supervised activities and students' PHEEM scores ( r  = 0.165, P  < 0.10).
Conclusions  The results suggest that the time spent on activities involving direct patient contact is positively related to students' perceptions of the quality of their learning environment. None of the activities were significantly negatively related to the students' perceptions of their clinical learning environment. Future research should examine the optimal time allocations required to enhance the perceived quality of the clinical learning environment.     

The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession?

Objective  Clinical experiences and gender have been shown to influence medical students' specialty choices. It remains unclear, however, which aspects of experiences make students favour some specialties and reject others. This study aimed to clarify the effects of clerkships on specialty choice and to identify explanatory factors.
Methods  We carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery ( n  = 200), internal medicine ( n  = 277) and general practice ( n  = 184). Regression analyses were performed to identify the determinants of career choice and the role of gender.
Results  Exposure to clinical settings encourages students to opt for a career in the corresponding specialty. Men were more stimulated than women by the general practice clerkship. Gender had no clear role as a predictor of career preference. The major predictor of career choice in all 3 specialties was positive evaluation of work-intrinsic factors. A preference for working with acute patients and technology-oriented work, prestige orientation and insignificance of a controllable lifestyle were determinants of a preference for surgery. Students with a preference for general practice had almost opposite preferences. Those who chose internal medicine favoured a controllable lifestyle.
Discussion  Factors other than gender appear to drive specialty decisions. Work content, type of patients and lifestyle options play major roles. Consequently, along with teaching about the practice of medicine, the matching of specialty preferences with reality is an essential outcome of clerkships.     

Changes in biochemical indices of bone metabolism in post-menopausal women following a dietary intervention with fortified dairy products

Background:  In southern Europe, calcium supplementation alone is a common practice for osteoporosis prevention. The present study aimed to examine whether calcium supplementation alone could be as effective in achieving favourable changes on bone metabolism indices of Greek post-menopausal women as a holistic dietary approach combining consumption of dairy products fortified with calcium and vitamin D₃ and nutrition counselling sessions for five winter months.
Methods:  A sample of 101 post-menopausal women was randomised to a dairy intervention group (IG: n  = 39), receiving approximately 1200 mg of calcium and 7.5 μg of vitamin D₃ per day via fortified dairy products and attending biweekly nutrition counselling sessions; a calcium-supplemented group (SG: n  = 26) receiving a total of 1200 mg calcium per day; and a control group (CG: n  = 36).
Results:  Regarding insulin-like growth factor (IGF)-I, a higher increase was observed for the IG compared to the changes in the CG and the SG ( P  =   0.049). Regarding serum parathyroid hormone (PTH) levels, the increase observed in the CG was higher than the changes observed in the other two groups but the differences were of marginal significance ( P  =   0.055). No significant differences were observed among groups regarding the changes in serum osteocalcin and type I collagen cross-linked C-telopeptide levels.
Conclusions:  The application of a holistic intervention approach combining nutrition counselling and consumption of fortified dairy products for five winter months induced some more favourable changes in IGF-I and PTH levels compared to calcium supplementation alone. Intervention periods longer than 5 months might be required to achieve significant differences among groups for bone remodelling biomarkers as well.     

Transition to clinical training: influence of pre-clinical knowledge and skills, and consequences for clinical performance

Context  Many students experience a tough transition from pre-clinical to clinical training and previous studies suggest that this may constrict students' progress. However, clear empirical evidence of this is lacking. The aim of this study was to determine: whether the perceived difficulty of transition influences student performance during the first 2 weeks of clerkships; whether it influences students' overall performance in their first clerkship, and the degree to which the difficulty of transition is influenced by students' pre-clinical knowledge and skills levels.
Methods  Clerks ( n  = 83) from a university hospital and eight affiliated hospitals completed a questionnaire measuring the perceived difficulty of the transition period. Data collected included student scores on pre-clinical knowledge and skills, their performance during the second week of the first clerkship, and their overall performance in the first clerkship. Univariate and multivariate multiple regression analyses were used to analyse the data.
Results  The perceived difficulty of transition was neither predictive of student performance during the transition period (adjusted R ² = 11.8%, P  = NS), nor of their overall clerkship performance (adjusted R ² = 8.6%, P  = NS). Students' pre-clinical knowledge and skills played a minor role in the perceived difficulty of the transition period.
Conclusions  The negative effect of the transition period on student progress suggested in the literature was not found in this study. A possible explanation for the limited influence of students' knowledge and skills on performance during the transition period is that the workload in this period causes a cognitive overload, interfering with students' abilities to apply their pre-clinical knowledge and skills.     

A Longitudinal Analysis of Outcomes Associated with Abciximab and Eptifibatide in a Consecutive Series of 3074 Percutaneous Coronary Interventions

Background:  Although the efficacy of platelet glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) in reducing complication rates during percutaneous coronary intervention (PCI) is well established, comparative studies assessing currently approved agents as administered in current practice are limited. We studied the clinical and length of stay (LOS) outcomes of patients undergoing PCI who received either abciximab or eptifibatide.
Methods:  All patients undergoing elective, urgent, or emergency PCI at Mayo Clinic Rochester between November 17, 2000 and August 31, 2004 who received either abciximab or eptifibatide were included. Clinical, angiographic, and follow-up data were prospectively recorded in the Mayo Clinic PCI Registry; administrative data recorded LOS. We used logistic and Cox proportional hazard models to estimate the risk of adverse events and generalized linear modeling to predict LOS. Propensity score and standard risk adjustments were used to account for baseline differences.
Results:  A total of 2123 PCI patients received eptifibatide and 951 received abciximab. The adjusted odds ratio for in-hospital death and myocardial infarction (MI) with eptifibatide was 0.80 (95% CI 0.56–1.14, P  = 0.21) versus abciximab. Adjusted hazard ratios for death and MI and for death, MI, or target vessel revascularization during a median follow-up of 24.6 months were 0.84 (95% CI 0.68–1.02, P  = 0.08) and 0.95 (95% CI 0.81–1.11, P  = 0.53), respectively. Adjusted postprocedural LOS was similar at 3.4 days.
Conclusion:  This large observational study found no evidence of a clinical or LOS advantage to physician choice of either abciximab or eptifibatide during PCI in contemporary practice.     

Effects of ethanol on gut-associated lymphoid tissues in a model of bacterial translocation: a possible role of apoptosis

Chronic ethanol intake has been shown to be associated with immune suppression and impairment of epithelial barrier function. We investigated the effects of ethanol on intestinal immunity and its relation to bacterial translocation (BT). Male Wistar rats were assigned to one of three groups and received respective diets for 28 days. The ethanol-fed group [(EG); n = 11] received a liquid diet containing 5% [volume/volume (vol./vol.)] ethanol; a pair-fed group [(PFG); n = 11] received an isocaloric diet without ethanol; and a third (control) group [(CG); n = 11] received water and chow ad libitum. On experimental day 29, animals in the EG and the PFG underwent distal ileum ligature and small intestine inoculation of a tetracycline-resistant Escherichia coli strain (Tc^R E. coli R6), by means of gastric intubation, followed by duodenal ligature. One hour after inoculation, mesenteric lymph nodes, right lobe of liver, spleen, and left kidney were excised for bacterial studies. Sections of jejunum and colon were immunostained, with the use of antibodies against immunoglobulin (Ig) A, T cells, macrophages, and proliferating cell nuclear antigen (PCNA). Apoptosis was determined by the terminal deoxynucleotidyltransferase TdT-mediated dUDP-biotin nick end labeling (TUNEL) method. Bacterial translocation rates were greater in the PFG compared with findings for the EG. Lamina propria of the jejunum of the EG showed a reduction in the densities of IgA⁺ cells and T cells compared with findings for the PFG and the CG. Colonic lamina propria of the EG showed reduced densities of IgA⁺ cells and macrophages compared with findings for the PFG and the CG. Apoptotic index was increased in the EG compared with findings for the PFG and the CG, in both jejunum and colon. Proliferation index was not significantly different among groups. Results of the current study show that chronic ethanol ingestion led to a reduction of cellular and humoral components of the intestinal mucosa, possibly by cell loss as a result of ethanol-induced apoptosis. The reduced rates of BT observed after chronic ethanol intake seem to indicate that factors irrespective of immune function might be involved in BT inhibition.     

Student learning experiences in a longitudinal clerkship programme

Objective  To identify how medical student learning experiences in a new longitudinally integrated clinical clerkship (LICC) programme impacted students' learning.
Methods  We conducted semi-structured interviews with 12 medical students at three points in their training. We used an inductive, thematic analytic approach to data. Interviews ( n  = 35) were iteratively and independently coded by research team members to identify and corroborate key emergent themes.
Results  Students in the LICC programme reported slow but ongoing increases in patient responsibility, examination-driven learning, programme flexibility to address educational gaps, and a strong and positive perception of educational continuity through a longitudinal primary care educator and similar case mix throughout the year.
Conclusions  Student learning experiences in an LICC programme are both similar to and different from those in a traditional rotational clerkship programme. Students in the integrated clerkship were clear and unequivocal about the benefits of working with one teacher across time and caring for patients at different stages of the same disease in multiple settings. These findings have implications for clinical education development and design.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.     

Information needs and preferences of low and high literacy consumers for decisions about colorectal cancer screening: utilizing a linguistic model

Context  The use of written decision aids (DAs) in clinical practice has proliferated. However, few DAs have been developed for low literacy users, despite this group having low knowledge about healthcare and lacking involvement in health decisions.
Objective  To explore the information needs and understanding of adults with varying literacy in relation to colorectal cancer screening, and to consider their responses to two versions of a decision aid.
Participants  Thirty-three men and women aged 45–74 years were recruited from Adult Basic Education classes ( n  = 17) and University Continuing Education programs ( n  = 16).
Methods  We used qualitative methods (in-depth, semi-structured interviews) to compare and contrast the views of adults with lower and higher literacy levels, to gain a better understanding of how people with lower literacy value and interpret specific DA content and components; and determine whether needs and preferences are specific to lower literacy groups or generic across the broad literacy spectrum.
Results  Regardless of literacy perspective, participants' interpretations of the DA were shaped by their prior knowledge and expectations, as well as their values and preferences. This influenced perceptions of the DAs role in supporting informed decision making. A linguistic theoretical model was applied to interpret the findings. This facilitated considerations beyond the traditional focus on the readability of materials.
Conclusion  Decision aids developers may find it useful to apply alternative approaches (linguistic) when creating DAs for consumers of varying literacy.     

Feasiblity of The G.I. guide to increase knowledge about the glycaemic index in practice

Background Research findings support the application of the glycaemic index concept in the dietary treatment of diabetes. However, it is still unclear how to use this concept in general practice. The G.I. guide was accordingly developed to be used as an educational tool when introducing the glycaemic index in practice.
Methods A sample of 21 professionals involved with the treatment of diabetes (expert population), and 18 individuals with diabetes (lay population), were included in a pilot study to determine the feasibility of The G.I. guide to increase knowledge about the glycaemic index in practice. All participants were asked to complete a knowledge questionnaire on the glycaemic index before and directly after meeting and discussing The G.I. guide.
Results The mean change in knowledge about the glycaemic index before and after being exposed to The G.I. guide was highly significant in both the expert ( P  < 0.0001) and the lay group ( P  < 0.0001). The G.I. guide did not change lay or expert participants' opinions about healthy eating guidelines.
Conclusion The G.I. guide was effective in increasing knowledge and raising interest about the glycaemic index in practice.     

Optimal sequencing of bedside teaching and computer-based learning: a randomised trial

Objectives  We aimed to establish the most effective order in which to deliver teaching to medical students when using both bedside teaching (BT) and computer-based learning (CBL) and to ascertain the students' preferred method and order of delivery.
Methods  A sample of 28 medical students were randomly divided into two equal groups during their orthopaedic knee examination teaching session. Group 1 received standard BT and group 2 undertook a CBL package. Each group then undertook an objective structured clinical examination (OSCE). The groups then received the other method of teaching followed by another OSCE. A questionnaire was administered to all students to assess their views on, and preferences for, the various teaching methods.
Results  Mean scores on the first OSCE were 12.19 for group 1 (BT then CBL) and 11.96 for group 2 (CBL then BT) ( P  = 0.692). Mean scores on the second OSCE were 11.81 for group 1 compared with 12.79 for group 2 ( P  = 0.038). Statistical analysis showed a significantly better score improvement for group 2 (CBL then BT) over group 1 (BT then CBL). Of the 26 students who returned questionnaires, 24 (92%) expressed their preference for traditional BT over CBL only, and 23 (88%) were in favour of undertaking CBL prior to traditional BT.
Conclusions  The CBL package is a useful tool and is most effective if used before BT. Students prefer BT alone over CBL alone, but, if offered both, prefer to undertake CBL first.     

Effects of reflective practice on the accuracy of medical diagnoses

Context  Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy.
Methods  Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables.
Results  A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P  < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases.
Conclusions  Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors.     

Planning for the end of children's lives – the lifetime framework

Aim   This paper describes the development of 'a best practice framework', following review of a sample of notes of children known to the Lifetime Service, where the child has a non-malignant life limiting condition, to improve child and family engagement in the planning process at the end of life.
Background   There is very little literature about how to engage with families to decide end of life plans for children with life limiting conditions.
Method   An audit of clinical case notes was followed by the development of 'a best practice framework' through a Delphi process involving clinical practitioners.
Results   The 3 × 3 framework is presented to aid communication with parents and children at this difficult time of decision-making.
Conclusion   This new framework has been well received by both parents and practitioners, and its use will be audited in the future.     

Does maternal knowledge and parent education affect blood phenylalanine control in phenylketonuria?

Background  Metabolic control in phenylketonuria (PKU) may be influenced by parental ability because dietary treatment involves complex food choices. This is an observational study to compare maternal carer (MC) knowledge and parental education with phenylalanine concentrations in children with PKU.
Methods  Children ( n  = 46; 26 boys) aged 1–10 years (median age 6 years) on dietary treatment were recruited. Their median lifetime and median phenylalanine concentrations in the year prior to study were estimated. MC completed a questionnaire to assess dietary knowledge.
Results  Overall maternal knowledge on most aspects of diet was good and there was a correlation between annual median blood phenylalanine concentrations, but at the age of 5–6 years of age only, and higher maternal carer scores on PKU knowledge ( r  = −0.646; P  < 0.0001). Three of only four children (12%) with median phenylalanine concentrations above 500 μmol L⁻¹ in the year prior to study had both parents leave school without educational qualifications. Children who had median phenylalanine concentrations ( n  = 3; 7%) over the recommended ranges at 3 years of age or earlier continued to have poor control.
Conclusions  Blood phenylalanine control within the first 3 years of age, poor parental educational achievement at school level, and unsatisfactory maternal dietary knowledge may all influence longer-term blood phenylalanine control in children.